Pneumonia knowledge and care seeking behavior for children under-five years in Jigawa, Northwest Nigeria: a cross-sectional study

Background

Between 2013 and 2022, Nigeria did not meet globally defined targets for pneumonia control, despite some scale-up of vaccinations, oxygen and antibiotics. A deliberate focus on community-based programs is needed to improve coverage of protective, preventive and treatment interventions. We therefore aimed to describe caregiver knowledge and care seeking behaviour for childhood pneumonia, in a high child mortality setting in Nigeria, to inform the development of effective community-based interventions for pneumonia control.

Methods

We conducted a cross-sectional household survey in Kiyawa Local Government Area, Jigawa State, Nigeria between December 2019 and March 2020. We asked caregivers about their knowledge of pneumonia symptoms, prevention, risks, and treatment. A score of 1 was assigned for each correct response. We showed them videos of pneumonia specific symptoms and asked (1) if their child had any respiratory symptoms in the 2-weeks prior; (2) their subsequent care-seeking behaviour. Multivariate regressions explored socio-demographic and clinical factors associated with care seeking.

Results

We surveyed 1,661 eligible women, with 2,828 children under-five. Only 4.9% of women could name both cough and difficulty/fast breathing as pneumonia symptoms, and the composite knowledge scores for pneumonia prevention, risks and treatment were low. Overall, 19.0% (536/2828) of children had a report of pneumonia specific symptoms in the prior two-weeks, and of these 32.3% (176/536) were taken for care. The odds of care seeking was higher among children: with fever (AOR:2:45 [95% CI: 1.38-4.34]); from wealthiest homes (AOR: 2:13 [95% CI: 1.03-4.38]) and whose mother first married at 20-26 years compared to 15-19 years (AOR: 5.15 [95% CI: 1.38-19.26]). Notably, the caregiver's knowledge of pneumonia was not associated with care seeking.

Conclusion

While some socio-demographic factors were associated with care seeking for children with symptoms of Acute Respiratory Infection (ARI), caregiver's knowledge of the disease was not. Therefore, when designing public health interventions to address child mortality, information-giving alone is likely to be insufficient.

Prevalence of pneumonia and malnutrition among children in Jigawa state, Nigeria: a community-based clinical screening study

OBJECTIVE

To estimate the point prevalence of pneumonia and malnutrition and explore associations with household socioeconomic factors.

DESIGN

Community-based cross-sectional study conducted in January-June 2021 among a random sample of households across all villages in the study area.

SETTING

Kiyawa Local Government Area, Jigawa state, Nigeria.

PARTICIPANTS

Children aged 0-59 months who were permanent residents in Kiyawa and present at home at the time of the survey.

MAIN OUTCOME MEASURES

Pneumonia (non-severe and severe) defined using WHO criteria (2014 revision) in children aged 0-59 months. Malnutrition (moderate and severe) defined using mid-upper arm circumference in children aged 6-59 months.

RESULTS

9171 children were assessed, with a mean age of 24.8 months (SD=15.8); 48.7% were girls. Overall pneumonia (severe or non-severe) point prevalence was 1.3% (n=121/9171); 0.6% (n=55/9171) had severe pneumonia. Using an alternate definition that did not rely on caregiver-reported cough/difficult breathing revealed higher pneumonia prevalence (n=258, 2.8%, 0.6% severe, 2.2% non-severe). Access to any toilet facility was associated with lower odds of pneumonia (aOR: 0.56; 95% CI: 0.31 to 1.01). The prevalence of malnutrition (moderate or severe) was 15.6% (n=1239/7954) with 4.1% (n=329/7954) were severely malnourished. Being older (aOR: 0.22; 95% CI: 0.17 to 0.27), male (aOR: 0.77; 95% CI: 0.66 to 0.91) and having head of compound a business owner or professional (vs subsistence farmer, aOR 0.71; 95% CI: 0.56 to 0.90) were associated with lower odds of malnutrition.

CONCLUSIONS

In this large, representative community-based survey, there was a considerable pneumonia and malnutrition morbidity burden. We noted challenges in the diagnosis of Integrated Management of Childhood Illness-defined pneumonia in this context.

Pulse oximetry and oxygen services for the care of children with pneumonia attending frontline health facilities in Lagos, Nigeria (INSPIRING-Lagos): study protocol for a mixed-methods evaluation

INTRODUCTION

The aim of this evaluation is to understand whether introducing stabilisation rooms equipped with pulse oximetry and oxygen systems to frontline health facilities in Ikorodu, Lagos State, alongside healthcare worker (HCW) training improves the quality of care for children with pneumonia aged 0-59 months. We will explore to what extent, how, for whom and in what contexts the intervention works.

METHODS AND ANALYSIS

Quasi-experimental time-series impact evaluation with embedded mixed-methods process and economic evaluation.

SETTING

seven government primary care facilities, seven private health facilities, two government secondary care facilities.

TARGET POPULATION

children aged 0-59 months with clinically diagnosed pneumonia and/or suspected or confirmed COVID-19.

INTERVENTION

'stabilisation rooms' within participating primary care facilities in Ikorodu local government area, designed to allow for short-term oxygen delivery for children with hypoxaemia prior to transfer to hospital, alongside HCW training on integrated management of childhood illness, pulse oximetry and oxygen therapy, immunisation and nutrition. Secondary facilities will also receive training and equipment for oxygen and pulse oximetry to ensure minimum standard of care is available for referred children.

PRIMARY OUTCOME

correct management of hypoxaemic pneumonia including administration of oxygen therapy, referral and presentation to hospital.

SECONDARY OUTCOME

14-day pneumonia case fatality rate. Evaluation period: August 2020 to September 2022.

ETHICS AND DISSEMINATION

Ethical approval from University of Ibadan, Lagos State and University College London. Ongoing engagement with government and other key stakeholders during the project. Local dissemination events will be held with the State Ministry of Health at the end of the project (December 2022). We will publish the main impact results, process evaluation and economic evaluation results as open-access academic publications in international journals.

TRIAL REGISTRATION NUMBER

ACTRN12621001071819; Registered on the Australian and New Zealand Clinical Trials Registry.

Integrated Sustainable childhood Pneumonia and Infectious disease Reduction in Nigeria (INSPIRING) through whole system strengthening in Jigawa, Nigeria: study protocol for a cluster randomised controlled trial

BACKGROUND

Child mortality remains unacceptably high, with Northern Nigeria reporting some of the highest rates globally (e.g. 192/1000 live births in Jigawa State). Coverage of key protect and prevent interventions, such as vaccination and clean cooking fuel use, is low. Additionally, knowledge, care-seeking and health system factors are poor. Therefore, a whole systems approach is needed for sustainable reductions in child mortality.

METHODS

This is a cluster randomised controlled trial, with integrated process and economic evaluations, conducted from January 2021 to September 2022. The trial will be conducted in Kiyawa Local Government Area, Jigawa State, Nigeria, with an estimated population of 230,000. Clusters are defined as primary government health facility catchment areas (n = 33). The 33 clusters will be randomly allocated (1:1) in a public ceremony, and 32 clusters included in the impact evaluation. The trial will evaluate a locally adapted 'whole systems strengthening' package of three evidence-based methods: community men's and women's groups, Partnership Defined Quality Scorecard and healthcare worker training, mentorship and provision of basic essential equipment and commodities. The primary outcome is mortality of children aged 7 days to 59 months. Mortality will be recorded prospectively using a cohort design, and secondary outcomes measured through baseline and endline cross-sectional surveys. Assuming the following, we will have a minimum detectable effect size of 30%: (a) baseline mortality of 100 per 1000 livebirths, (b) 4480 compounds with 3 eligible children per compound, (c) 80% power, (d) 5% significance, (e) intra-cluster correlation of 0.007 and (f) coefficient of variance of cluster size of 0.74. Analysis will be by intention-to-treat, comparing intervention and control clusters, adjusting for compound and trial clustering.

DISCUSSION

This study will provide robust evidence of the effectiveness and cost-effectiveness of community-based participatory learning and action, with integrated health system strengthening and accountability mechanisms, to reduce child mortality. The ethnographic process evaluation will allow for a rich understanding of how the intervention works in this context. However, we encountered a key challenge in calculating the sample size, given the lack of timely and reliable mortality data and the uncertain impacts of the COVID-19 pandemic.

TRIAL REGISTRATION

ISRCTN 39213655 . Registered on 11 December 2019.

A mixed-methods evaluation of stakeholder perspectives on pediatric pneumonia in Nigeria-priorities, challenges, and champions

BACKGROUND

Interventions to reduce pneumonia mortality exist; however, stakeholder engagement is needed to prioritize these. We explored diverse stakeholder opinions on current policy challenges and priorities for pediatric pneumonia in Nigeria.

METHODS

We conducted a mixed-methods study, with a web-survey and semi-structured interviews, to explore stakeholder roles, policy barriers, opportunities, and priorities. Web-survey participants were identified through stakeholder mapping, including researchers' networks, academic and grey literature, and "Every Breath Counts" coalition membership. Stakeholders included actors involved in pediatric pneumonia in Nigeria from non-governmental, government, academic, civil society, private, and professional organizations. Stakeholder interviews were conducted with local government, healthcare managers, professional associations, and local leaders in Lagos and Jigawa states. Quantitative data were analyzed descriptively; qualitative data were analyzed using a thematic framework.

RESULTS

Of 111 stakeholders, 38 (34%) participated in the web-survey and 18 stakeholder interviews were conducted. Four thematic areas emerged: current policy, systems barriers, intervention priorities, and champions. Interviewees reported a lack of pneumonia-specific policies, despite acknowledging guidelines had been adopted in their settings. Barriers to effective pneumonia management were seen at all levels of the system, from the community to healthcare to policy, with key issues of resourcing and infrastructure. Intervention priorities were the strengthening of community knowledge and improving case management, focused on primary care. While stakeholders identified several key actors for pediatric pneumonia, they also highlighted a lack of champions.

CONCLUSION

Consistent messages emerged to prioritize community and primary care initiatives, alongside improved access to oxygen, and pulse oximetry. There is a need for clear pneumonia policies, and support for adoption at a state level.